At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?
Constipation
Indigestion
Swollen ankles
Urinary frequency
None
None
The Correct Answer is B
A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.
B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.
C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."
D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Discarding opened cans of formula after 24 hours helps prevent bacterial contamination and growth, which can contribute to diarrhea in clients receiving enteral feedings.
B. Extension tubing should be replaced according to institutional policy and manufacturer recommendations, typically every 24 to 48 hours, but it is not directly related to diarrhea management.
C. Irrigating the tubing with warm water is not a standard practice for managing diarrhea in clients receiving enteral feedings and may disrupt the client's fluid and electrolyte balance.
D. Increasing the infusion rate of enteral feedings is not indicated for managing diarrhea and may exacerbate the problem by overwhelming the client's gastrointestinal tract. The rate of enteral feeding should be adjusted based on the client's nutritional needs and tolerance, as determined by the healthcare provider.
Correct Answer is B
Explanation
A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.
B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.
C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.
D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.
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